The rhetoric of the Academy of Medical Sciences, the medical royal colleges, and medical researchers is that the future of healthcare is bright. Personalised medicine is coming; diseases that are currently incurable will be cured; life expectancy will increase; big data will bring untold benefits; and the quality of care will steadily improve. But through judging a short story competition about the future of health and healthcare in 2100, I’ve learnt that science fiction writers, probably better predictors of the future than the medical establishment, see the future as universally bleak.

Writing the Future is a competition organised by Kaleidoscope Health & Care that invited science-fiction short stories about health and healthcare in the UK in 2100. There were no other stipulations apart from a rule that the stories couldn’t be more than 3000 words. (Most of the stories I read were something like 2995 words, which was, I thought, a mistake.) There were some 150 entries, and I read around 20 – 15 where together with two other judges I had to shortlist five and then five or six others that three other judges had shortlisted. The short list of six is being published this week, and the winner of the prize of £10 000 will be announced on 26 October.

I won’t say much about the judging process except to say there was lots of disagreement, some of it vehement. But another judge said the disagreement was nothing compared with the “blood on the walls” of the last competition he judged. Writing stories, as opposed to blogs or essays, is hard: most people, including I’m sure me, can’t do it well.

The themes of the stories, most of them recurrent, were what fascinated me. I read only one story that imagined a brighter future, and even that was full of problems. The very developments that health researchers see offering great promise—genetics, big data, and artificial intelligence—were the source of much of the bleakness. Many stories imagined a world like that of Orwell where sinister health police knew everything about individuals and allowed no deviation from the pursuit of health. There was no freedom, creativity, spontaneity, meaning, or fun. Brave individuals—“terrorists”—fought the system but usually failed. Genetic analysis meant that your life course was known from birth, creating more pain than satisfaction. Babies could be designed, but for what?

In many of the stories doctors had ceased to be necessary to do anything technical. Diagnosis and surgery were undertaken by robots and avatars, leaving a question about the role of human doctors. They were useful for human things like empathising, being compassionate, hugging, listening, and getting confused. But there was a sense that human doctors wouldn’t be needed much longer. Robots can learn from humans how to be compassionate and having worked out the “rules of compassion” can soon do it better.

Some of the stories flirted with immortality, an implicit aim of medicine for some time. But immortality is unbearable as, indeed, is life generally in 2100—thanks mostly to medicine.

In many of the stories inequality had increased dramatically. The poor, akin to Orwell’s proles, labour and die shut out from the miracles of medicine. Meanwhile, the elite, Orwell’s party members, have every medical privilege—nanotechnology being used to keep every cell and organ in perfect shape or every organ transplanted as necessary with new organs grown in laboratories—but are oppressed by the privileges.

The NHS has, of course, collapsed in most stories. Vast and faceless corporations run healthcare and put their own interests ahead of those of patients and citizens.

The aim of the competition was to bring new ideas and creative thinking, but just as it’s hard to write a compelling story so it’s hard to be really creative. The easy thing is to project forward what’s new at the moment—so the stories were stuffed with nanotechnology, robot surgeons, gene therapy, virtual reality, avatars, tissue engineering, artificial intelligence, the downloading of brains, personalised medicine, and big data. Reading similar stories one after another, judges long for something different; so my advice for those entering future competitions is to try and imagine what everybody else is going to write and then write something different. I also advise concentrating on one issue and exploring it in depth rather than trying to throw in everything.

As well as being fascinated by the subjects covered in the stories I was interested by what was not there. I was surprised and disappointed that there wasn’t more on climate change and antimicrobial resistance: these are slow-moving but powerful forces that will have a huge impact over a century, whereas flashier innovations of the moment may be entirely forgotten. As always seems to be the case in discussions of health, healthcare dominated and health was largely ignored.

The value of this exercise, I concluded, was not in the individual stories, few of which excited, but in the totality. I’ve picked out a few themes (and non-themes) from the 20 or stories I read, but the organisers will be publishing a more systematic and complete analysis of all 150 stories.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS was not paid for judging the competition and has no financial connection with the company that organised the competition.

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